System and method for intelligent management of medical care

ABSTRACT

A computerized medical care system provides validation of a diagnosis of a medical condition and requested medical services for treating the medical condition. The medial care system invokes multiple filters to determine the appropriateness of the diagnosis and medical service. Real time feedback is provided based on the determination. If the medical care cannot be validated, the feedback includes the reasons for the failure to validate, and any supporting materials for the lack of validation. The feedback may also prompt the requesting entity to provide additional information to help support the medical provider&#39;s position as to why the requested medical care is appropriate.

CROSS-REFERENCE TO RELATED APPLICATIONS

This application is a continuation of U.S. application Ser. No.13/154,338 filed Jun. 6, 2011, which is a continuation of U.S.application Ser. No. 12/197,063 filed Aug. 22, 2008, which claims thebenefit of U.S. Provisional Application No. 60/968,032, filed Aug. 24,2007, the content of all of which are incorporated herein by reference.

FIELD OF THE INVENTION

The present invention is generally related to computer systems in thefield of managed care, and more particularly, to a computerized medicalcare system for managing and delivering information to members of themedical service industry useful for providing efficient and improvedservices to patients.

BACKGROUND

One problem encountered by both physicians and patients in the managedcare system is the delays it causes. Studies reveal that in many cases,managed care organizations delay responses to requests for medicalservices for more than two or three days. Physicians feel it isnon-physicians managing the system who have no medical training thatcauses the delay. Patients feel that the system is designed to denyrather than improve services. Despite the reasons, studies reveal thatthe delays are too often dangerous for the patient.

In this regard, the managed care system often requires service providersto seek authorization before providing certain services for a customer.In some cases, such authorization is improperly denied, to the detrimentof the customer's welfare. The denial may arise because individuals whodecided to deny the authorization were not sufficiently knowledgeableand/or because the individuals did not have the proper and/or necessaryinformation at their disposal at the time of the decision. Althoughhistorically, management of medical care and delivery of services werein the hands of physicians, more recently, the management of medicalcare has been relegated to persons who are not physicians. This changeis mainly due to an attempt to control the increasingly excessive costsassociated with those medical services.

As one example, in an industry such as the health-care industry, certainservices may be denied to a patient because decision-makers do not haveat their disposal information that would support a decision to grant theservices. For example, medical providers may use diagnostic codes toidentify certain medical conditions. Based on an erroneous diagnosticcode entered by a provider, an administrator may improperly deny apatient a certain service, e.g., a magnetic resonance imaging (MRI) ofthe shoulder. Although a review of the patient's medical history (e.g.,medical chart) would have revealed instances of arthritis which wouldhave made an MRI appropriate, an erroneously entered diagnostic code foran instance of trauma instead of arthritis results in the denial of theMRI. As such, medical personnel attending to the patient cannot performthe MRI, which should have been performed to treat the patient'sarthritis.

As another example, reimbursement for services already provided is notapproved because authorization for the services was not previouslygranted. For example, a coma victim may be refused reimbursement forcosts associated with traveling to the hospital via ambulance becauseauthorization for this service was not granted before the service wasprovided.

Studies also reveal that the nurses and managed care personnel oftenmake decisions with insufficient information, and achieve resultscontrary to the best interests of the patient.

Another problem with current managed care systems is the high costsassociated with such systems. The average cost to insurance companiesfor delivery of managed care plans ranges between $50 and $150. Thereason for the increased cost is because the nursing staff, who isrequired to make the decisions, may take from a few hours to a few days,in making such decisions.

Prior art systems and methods exist for allowing a claims processingperson to detect fraudulent medical claims that are submitted forreimbursement or payment. Although such prior art systems analyze thesubmitted service codes during claims processing, such analysis is forensuring that the payment for the medical services that were alreadyprovided is appropriate. The analysis is not for improving the medicalservices that are provided to patients, nor to allow those medicalservices to be provided more efficiently.

In fact, because the submitting of the claim generally means that theservice has already been performed, even if a prior art system were tosubstitute a procedure code that is listed in a medical claim forpayment with another more appropriate code, the medical provider wouldnot be able to change the actual procedure that would already have beenperformed. This may be a detriment to not only a patient that could havereceived a more appropriate service, but also to the rendering medicalprovider who is only able to get reimbursed for the procedure thatshould have been provided, but not the service that was actuallyprovided.

As such, there is a need for a computerized medical care system forproviding service providers and service personnel with information thatis useful in providing an improved and more efficient level of serviceto the customers that they serve.

SUMMARY OF THE INVENTION

According to one embodiment, a method for providing a medicalpre-approval in a computerized medical care system includes receivingfrom a requesting device a medical code associated with a medicaldetermination; identifying one or more filters enabled for thecomputerized medical care system; applying the identified one or morefilters for the received medical code; determining validity of themedical determination based on the applied one or more filters; andproviding feedback to the requesting device based on the determinationof the validity of the medical determination. The feedback promptsmodification of the medical determination that is ultimately rendered toa patient if the medical determination is not validated.

According to one embodiment of the invention, the medical code is adiagnosis code, the medical determination is diagnosis of a medicalcondition, and the one or more filters includes a medical diagnosisfilter, wherein the feedback is configured to prompt modification of thediagnosis that is ultimately rendered to the patient if the diagnosis isnot validated.

According to one embodiment of the invention, the applying of themedical diagnosis filter and the determining of the validity of thediagnosis includes displaying a question that should be considered inmaking the diagnosis of the medical condition; prompting a user responseto the displayed question; receiving the user response to the displayedquestion; comparing an expected response to the displayed question withthe received user response; and validating the diagnosis if the expectedresponse matches the received user response.

According to one embodiment of the invention, the method includes addingto a historical database information on the validity of the diagnosiscode in association with a medical provider providing the diagnosiscode; calculating based on information in the historical database aratio of collected diagnosis codes that have not been validated tocollected diagnosis codes that have been validated; and generating areport based on the ratio information.

According to one embodiment of the invention, the feedback is a letterincluding information on the validity of the diagnosis, where the letteris generated in real time with the validating of the diagnosis.

According to one embodiment of the invention, the medical code is aservice code, the medical determination is a medical service determinedbased on a diagnosed medical condition, and the filters include aplurality of medical procedure filters, wherein the feedback isconfigured to prompt modification of the medical service that isultimately rendered to the patient if the medical service is notvalidated.

According to one embodiment of the invention, each of the plurality ofmedical procedure filters are applied one by one in sequence.

According to one embodiment of the invention, the method furtherincludes providing a graphical user interface with a list of theplurality of medical procedure filters; receiving a user selection ofdesired ones of the plurality of medical procedure filters; and enablingeach selected medical procedure filter for applying in making thevalidity determination of the determined medical service.

According to one embodiment of the invention, the applying of at leastone of the plurality of medical procedure filters includes analyzinghistorical data collected in association with the service code from ahistorical database; determining based on the analyzed historical datawhether the medical service is statistically reasonable; and returning aresult of applying at least one of the plurality of medical procedurefilters based on the determination.

According to one embodiment of the invention, the method furtherincludes adding to the historical database information on the medicalservice requested for the medical condition.

According to one embodiment of the invention, at least one of theplurality of medical procedure filters is a heat filter, and theapplying of the heat filter includes identifying a date of injury;identifying a timing of the medical service, wherein the medical serviceis a heat-based therapy; determining whether the timing of theheat-based therapy is appropriate relative to the date of injury; andreturning a result of applying the heat filter based on thedetermination.

According to one embodiment of the invention, at least one of theplurality of medical procedure filters is a rarity filter. The applyingof the rarity filter includes retrieving historical data of medicalservices provided for the diagnosed medical condition; identifying arate in which the determined medical service was provided for theidentified diagnosis based on the retrieved historical data; identifyinga threshold rate; determining whether the identified rate satisfies thethreshold rate; and returning a result of applying the rarity filterbased on the determination.

According to one embodiment of the invention, at least one of theplurality of medical procedure filters is a utilization filter. Theapplying of the utilization filter includes receiving information on arequested number of visits or duration of care for the identifiedservice code; analyzing historical data of previous number of visits ordurations of care provided for the diagnosed medical condition;identifying a threshold number of visits or durations of care based onthe analyzed historical data; determining whether the requested numberof visits or duration of care satisfies the threshold number of visitsor duration of care; and returning a result of applying the utilizationfilter based on the determination.

According to one embodiment of the invention, at least one of theplurality of medical procedure filters is a level of service filter. Theapplying of the level of service filter includes identifying a level ofservice associated with the identified service code; analyzinghistorical data of previous levels of service provided for the diagnosedmedical condition; identifying a threshold level of service based on theanalyzed historical data; determining whether the identified level ofservice satisfies the threshold level of service; and returning a resultof applying the level of service filter based on the determination.

According to one embodiment of the invention, at least one of theplurality of medical procedure filters is a billing guidelines filter.The applying of the billing guidelines filter includes receiving arequested charge amount for the determined medical service; identifyinga billing guideline associated with the determined medical service;determining whether the requested charge amount satisfies the identifiedbilling guideline; and returning a result of applying the billingguidelines filter based on the determination.

According to one embodiment of the invention, at least one of theplurality of medical procedure filters is a charges filter. The applyingof the charges filter includes receiving a requested charge amount forthe determined medical service; analyzing historical data of previouscharges for the diagnosed medical code; identifying a threshold chargeamount based on the analyzed historical data; determining whether theidentified charge amount satisfies the threshold charge amount; andreturning a result of applying the charges filter based on thedetermination.

According to one embodiment of the invention, the feedback is a letterincluding information on the validity of the medical service, where theletter is generated in real time with the validating of the determinedmedical service.

According to one embodiment of the invention, the applying of at leastone of the plurality of medical procedure filters includes identifying aspecific patient for which the medical service is requested; retrievinghistorical data of medical care provided to the specific patient;determining based on the retrieved historical data whether thedetermined medical service is appropriate for the specific patient; andreturning a result of applying the at least one of the plurality ofmedical procedure filters based on the determination.

According to another embodiment, the present invention is directed to acomputerized medical care system for providing a medical pre-approval.The system includes a processor and memory operably coupled to theprocessor. The memory stores program instructions that are executed bythe processor for receiving from a requesting device a medical codeassociated with a medical determination; identifying one or more filtersenabled for the computerized medical care system; applying theidentified one or more filters for the received medical code;determining validity of the medical determination based on the appliedone or more filters; and providing feedback to the requesting devicebased on the determination of the validity of the medical determination,wherein the feedback prompts modification of the medical determinationthat is ultimately rendered to a patient if the medical determination isnot validated.

According to another embodiment, the present invention is directed to acomputerized medical care system for providing a medical pre-approval.The system includes a computing engine configured to receive a diagnosiscode identifying diagnosis of a medical condition and a service codeidentifying a requested medical service; a medical diagnosis filtercoupled to the engine and configured to display a question that shouldbe considered in making the diagnosis of the medical condition, themedical diagnosis filter further being configured to prompt a userresponse to the displayed question, validate the diagnosis if theexpected response matches the received user response, and invalidate thediagnosis if the expected response fails to match the received userresponse; and a plurality of medical procedure filters coupled to theengine and configured to determine a validity of the requested medicalservice relative to the diagnosis based on each of the applied medicalprocedure filters. The computing engine is configured to providefeedback based on the determination of the validity of the diagnosis andrequested medical service. The feedback prompts modification of thediagnosis or medical service that is ultimately rendered to a patient ifrespectively the diagnosis or requested medical service is notvalidated.

It should therefore be appreciated that aspects of the present inventionare directed to a system and a method for validating a diagnosis andmedical service submitted by a provider, before such medical service isactually rendered. This helps protect the welfare of the patients.Furthermore, the likelihood of misdiagnosis is reduced, and thelikelihood that the treatment delivered will help heal the patient isincreased.

BRIEF DESCRIPTION OF THE DRAWINGS

These and other features, aspects, and advantages of the presentinvention will become better understood with regard to the followingdescription, appended claims, and accompanying drawings, where:

FIG. 1 is a functional block diagram of a computerized medical caresystem in accordance with an exemplary embodiment of the presentinvention;

FIG. 2 is a screen capture of a login interface in accordance with anexemplary embodiment of the present invention;

FIG. 3 is a screen capture of a starting interface in accordance with anexemplary embodiment of the present invention;

FIG. 4 is a screen capture of a claim search interface in accordancewith an exemplary embodiment of the present invention;

FIG. 5 is a screen capture of a provider search interface in accordancewith an exemplary embodiment of the present invention;

FIG. 6 is a screen capture of a medical code search interface inaccordance with an exemplary embodiment of the present invention;

FIG. 7 is a screen capture of a validation interface in accordance withan exemplary embodiment of the present invention;

FIG. 8 is a screen capture of a first procedure results interface inaccordance with an exemplary embodiment of the present invention;

FIG. 9 is a screen capture of a second procedure results interface inaccordance with an exemplary embodiment of the present invention;

FIG. 10 is a screen capture of a reporting interface according to oneembodiment of the invention;

FIGS. 11A-11D are examples of response letters produced via a reportinginterface according to an embodiment of the present invention;

FIG. 12 is a flow diagram of a pre-approval process according to oneembodiment of the invention;

FIG. 13 is a screen capture of a screen listing various organizationsthat a user may select in order to enable filters associated with theselected organizations according to one embodiment of the invention;

FIG. 14A is a flow diagram of a process for validating a medicaldiagnosis according to one embodiment of the invention;

FIG. 14B is a flow diagram of a process for validating a diagnosis ofICD-9 code 850.0 according to one embodiment of the invention;

FIG. 15 is a screen capture of a graphical user interface listingvarious history based filters that may be enabled by a user according toone embodiment of the invention;

FIG. 16 is a generalized flow diagram for applying at least some historybased filters according to one embodiment of the invention;

FIG. 17 is a flow diagram for applying a heat filter according to oneembodiment of the invention;

FIG. 18 is a flow diagram for applying a rarity filter according to oneembodiment of the invention;

FIG. 19 is a flow diagram for applying a level of service filteraccording to one embodiment of the invention;

FIG. 20 is a flow diagram for applying a billing guidelines filteraccording to one embodiment of the invention;

FIG. 21 is a flow diagram for applying a utilization filter according toone embodiment of the invention;

FIG. 22 is a flow diagram for applying a patient history filteraccording to one embodiment of the invention;

FIG. 23 is a flow diagram for applying a charges filter according to oneembodiment of the invention;

FIG. 24 is an exemplary screen capture of a graphical user interface forenabling a particular drug allowance guide for dispensing medicationsaccording to one embodiment of the invention;

FIG. 25 is an exemplary screen capture of a graphical user interface forselecting one or more of different types of claims that may be processedaccording to one embodiment of the invention;

FIG. 26 is an exemplary screen capture of a graphical user interface forselecting an unbundling medical filter and/or a medical literatureevidence based analysis according to one embodiment of the invention;and

FIG. 27 is an exemplary screen capture of a graphical user interface forselecting miscellaneous medical rules to be enabled for applying thoserules in the validating or invalidating of medical diagnoses and medicalprocedures according to one embodiment of the invention.

DETAILED DESCRIPTION

Exemplary embodiments of the present invention are directed to providinga method and system for collecting and storing information and using theinformation to animate a computer application.

In accordance with an exemplary embodiment, an organizational structurefor storing the information may be composed of elements that conform toa standardized programming language such as, for example, the extensiblemarkup language (XML) specification. As is known in the art, XML is amarkup language for documents containing structured information.Structured information contains both content (words, pictures, etc.) andsome indication of what function that content performs.

Features of the present invention may be best understood in the contextof a computerized medical care system that utilizes any of a variety ofuser interfaces. Such user interfaces may be invoked by or for a medicalprovider to provide to the medical care system, diagnostic code(s) andassociated procedure code(s) for receiving pre-approval of respectivelydiagnoses and medical services identified by such codes.

In the context of computerized medical care systems, third-party payorsand regulatory agencies often require that many (if not all)healthcare-related events and/or episodes be abstracted and described insummary fashion using a coding scheme that is specified in advance. Toprovide identifiers associated with various diseases and conditions,many coding schemes are in use and are suitable for this purpose. Forexample, the international classification of diseases (ICD) from theWorld Health Organization, the current procedural terminology (CPT) fromthe American Medical Association (AMA), and the systematic nomenclaturefor medicine (SNOMED) from the College of American Pathologists (CAP)are just a few of the currently available coding schemes that may beutilized to document primary diagnosis or prescribed medical procedures.

One skilled in the art will appreciate, however, that the presentinvention is not limited to medical record applications. Rather, thepresent invention is equally applicable to a variety of applicationsthat require the contemporaneous retrieval of records that must bevalidated, e.g., to meet financial and/or policy-related requirements.

The computerized medical care system according to the variousembodiments of the present invention provides validation of a diagnosisof a medical condition, validation of determined medical services,and/or validation of anticipated billings or charges for the determinedmedical services, that may be provided by a requesting entity (e.g. amedical service provider, case, manager, etc.) during a pre-approvalsession. In this regard, the medial care system invokes multiplefilters, either in parallel or in sequence one after another, todetermine the appropriateness of the diagnosis, medical service(s),and/or billings/charges (collectively referred to as medical care). Theappropriateness of the medical care may be based on information gatheredfrom a medical provider, information gathered from experts in themedical field, medical literature, and/or historical data on diagnoses,procedures, billings, and the like. According to one embodiment, thedetermination of whether the requested medical care is appropriate ismade on the spot during the pre-approval session.

According to one embodiment of the invention, feedback is provided inreal time with the validating of the diagnosis and the requested medicalcare. The feedback may be a message indicating approval/validation of adiagnosis, service, or billing. Alternately, the feedback may be amessage or letter indicating that the medical care cannot be currentlyvalidated. If the diagnosis or medical care cannot be validated, thefeedback includes the reasons for the failure to validate, and anysupporting materials for the lack of validation. The feedback may alsoprompt the requesting entity to provide additional information to helpsupport the medical provider's position as to why the medical diagnosisor care is appropriate.

The real-time feedback to the requesting device allows on the spotnotification of whether a submitted diagnosis and medical service hasbeen validated or not, such as, for example, within seconds after arequest for the approval has been transmitted to the medical caresystem. In this manner, patients benefit from the system because theapproval process does not delay the providing of needed medical care.Furthermore, the checking and validation of a diagnosis or a medicalservice to ensure that they are medically appropriate protects thepatient from diagnosis or prescription errors. If such errors are made,the present medical care system provides instant feedback of the errorto the medical provider, which prompts modification of the diagnosisand/or medical service, allowing for improved medical care for thepatients.

Medical service providers also benefit from the current system. Thevalidating of diagnoses and medical services before the services areactually rendered provides reassurance that the diagnoses and servicesare medically appropriate. Furthermore, the feedback of any errors thathave been detected which prompts the medical provider to modify thediagnoses or services to be rendered minimizes the risk of malpracticelawsuits. This is different from prior systems which focus is onanalyzing submitted codes for payment purposes after associated medicalservices have been rendered, but not appropriateness of services from amedical perspective for better medical care of the patient.

In addition to the above, the medical care system according to meembodiments of the present invention also allows medical serviceproviders to get paid or reimbursed by managed care organizations. Thatis, because expected charges are included in the pre-approval request,and filters may be enabled to validate the requested charges, theproviders are notified prior to the rendering of the services of thechances of any of the charges being denied. In this manner, the serviceprovider may modify the charges and/or procedures if the charges arelikely to be denied.

FIG. 1 is a simplified block diagram of an exemplary computerizedmedical care system according to an embodiment of the present invention.The system includes an artificial intelligence engine 12. In oneembodiment, the engine 12 is implemented using a mainframe server. Theengine 12 may utilize any of various filters to evaluate a claim that issubmitted before a requested medical service is provided. The datafilters may include, but are not limited to, CORE filters 131 for takingmedical procedure codes and providing an allowance, American College ofOccupational and Environmental Medicine (ACOEM) filters 132, correctcoding initiative (CCI) filters 133, fee schedule filters 134, currentprocedural terminology (CPT) filters 135, official disability guidelines(ODG) treatment filters 136, ODG disability filters 137, and utilizationfilters 138. These filters are collectively referred to as medicalprocedure filters, and are invoked for determining the medicalappropriateness of requested medical care based on various procedurerules. The system further includes one or more medical diagnosis filtersreferred to as DXMEDICUS filters 139 for validating or invalidating anentered diagnosis based on various diagnosis rules. The CORE filters andDXMEDICUS filtering software is commercially available from Medata, Inc,of Tustin, Calif.

The above-described filters are used to implement certain billingpractices and/or procedure guidelines. Some of the filters may be usedto implement practices and/or guidelines in conformance with certainindustry standards. For example, the CPT filters may be used toimplement practices and/or guidelines in conformance with the currentprocedural terminology (CPT) from the American Medical Association. Someof the filters may be designed to evaluate medical treatment and theimpact of the treatment with respect to a claim submitted by a medicalprovider.

As such, the above-described filters may be implemented as one or moresoftware modules. The modules may be executed by the engine 12 itself,or may be executed via in other computers (or computing devices) and/orservers interfacing with the engine 12. In this regard, the engine orother computing devices executing the engine includes a processor and amemory. The memory stores computer program instructions that areexecuted by the processor to receive a medical code (e.g. a diagnosticor procedure code), identify one or more enabled filters, generate aseries of prompts associated with each enabled filter for gatheringinformation specific to the diagnosis or medical service identified bythe code, and validate the medical code or not, based on the receivedresponses to the prompts. Exemplary applications of some of thesefilters will be described in more detail later.

The computerized medical care system also includes a database 140storing information used by the above filters in determining validity ofdiagnoses and medical procedures submitted by the medical provider 14.Such information may include, for example, historical data of theprocedures being performed for different diagnoses, historical datasurrounding the conditions of rendering the procedures, historical dataof charges being applied, and the like. The database may furthercorrelate the gathered historical data to individual patients, doctors,and/or or organizations. Reports may then be generated based on thecorrelated data. For example, a report may be generated with informationon how often a doctor's diagnoses and/or procedures fail to be validatedupon application of the various data filters provided by the system. Theratio of invalid diagnoses to valid diagnoses may then be provided inthe report.

Medical providers provide certain services to patients. With continuedreference to FIG. 1, a medical provider 10 having direct access to acomputer (or computing device) 101 can access (e.g., request informationand receive information from) the engine 12, over a data communicationsnetwork such as, for example, a local area network, private wide areanetwork, or the public Internet. However, an individual or an entity nothaving direct access to a computer can access the engine throughalternative routes.

For example, a medical provider 14 not having access to a computer canaccess the engine 12 via a client case manager 15, which, in turn,accesses the engine 12, via, for example, the World Wide Web. Here, themedical provider 14 may relay information to the client case manager 15,for example, in person or by telephone. The client case manager may thenrelay the information to the engine by way of the World Wide Web. Alsoby way of example, by virtue of its position, a client medical director11 can also access the engine 12.

As shown in FIG. 1, the medical provider 10 and the client medicaldirector 11 can interface with each other. Similarly, the medicalprovider 14 and the client medical director 11 can interface with oneanother.

To provide increased levels of security, interfaces between the computer101 and the engine 12 and between the client case manager 15 and theengine 12 can be guarded and monitored using firewalls 16. It will beappreciated by one skilled in the art that any suitable firewalls (e.g.,commercially available firewalls) may be used here.

Further, one skilled in the art will appreciate that the number andtypes of computers may vary in accordance with the setting (e.g.,clinical setting) of each application. For example, the computer 101 maybe a standard desktop personal computer, a notebook-style computer, apersonal digital assistant, or a mobile telephone.

The medical provider 10, 14 may use the above-described computerizedmedical care system before providing one or more services to a patient.Here, the medical provider 10, 14 enters certain pieces of informationduring a pre-approval session. In one embodiment, the pieces ofinformation include: an identifier associated with (or corresponding to)the patient, an identifier associated with the medical provider 10, 14providing the services, a particular condition(s) for which the medicalprovider 10, 14 is providing the services, the particular treatment(s)that the medical provider 10, 14 is proposing to use to treat thecondition, and optionally, charges associated with the particulartreatments.

In described exemplary embodiments, the computerized medical care systemis utilized for determining whether a requested diagnosis or procedureis medically adequate. However, one skilled in the art will appreciatethat the computerized medical care system may have other applicationsand can be used in other professions and/or industries having similardocumentation or pre-approval requirements. Therefore, the describedexemplary medical care systems are presented by way of illustration onlyand not by way of limitation.

With reference to FIG. 2, a provider 10 using the system is firstprompted by the system to log on the computerized medical care system byentering identifiers on the login screen 2. The required identifiers mayinclude a login ID 20 and a password 21.

The identifiers entered on the login screen 2 set forth the capabilitiesthat will be bestowed to the provider using the system. In contrast withan administrator of the system (who is allowed to use a wide range ofthe capabilities of the system, including changing options within thesystem), the provider 10 may be allowed to use only a more limited rangeof capabilities, commensurate with the scope of the capabilities grantedto it.

With reference to FIG. 3, after the provider 10 has entered a validcombination of login name 20 and password 21, the starting point screen3 is displayed. Here, the provider 10 can enter information in any ofvarious fields to seek authorization regarding a particular patient whois to be treated. For example, the provider 10 can enter a claim number31 that is associated with (or corresponds to) the patient. As anotherexample, the provider 10 can enter the name of the patient.

If a claim number 31 (or a portion of a claim number 31) is entered, thename of the corresponding patient (or names of corresponding patients)is displayed. With reference to FIG. 4, after the provider 10 hasentered a claim number 31 of “0,” a claim search 4 is displayed. Asshown in FIG. 4, the claim search 4 displays information relating tovarious patients associated with the entered claim number 31 of “0.” Forexample, in one embodiment, patients associated with the entered claimnumber 31 of “0” are those patients who have a claim 31 beginning withthe digit “0”: “Carmella Pappas,” “Casey Lewis,” “California Claimant,”and “Ryan Nicholas.” Here, the provider can select any one of thedisplayed patients. Alternatively, the provider 10 can enter the name ofthe patient to retrieve any and all patients having the entered name.

With reference to FIG. 5, the patient “Casey Lewis” associated with theclaim number 31 of “000004” is selected, and a provider search screen 5is displayed. As shown in FIG. 5, the provider search screen 5 displaysvarious providers associated with the patient “Casey Lewis”: In oneembodiment, the displayed providers are providers who have previouslyprovided services to the patient.

As shown in FIG. 5, the displayed providers that are associated with“Casey Lewis” are: “Brainjosiah,” “David Dozier, Jr MD” “Carl Dozier,DO” and “Henry Dozier, DC.” Here, any one (or more) of the displayedproviders can be selected such that more detailed information regardingthe services previously provided by the one (or more) displayed providerwill be displayed. In one embodiment, the provider 10 selects itself toretrieve information regarding the services that it previously providedto the patient. Alternatively, the provider 10 can enter, in the presentscreen, either an identifier associated with the provider (FEIN) or thename of the medical provider, which initiates a search screen.

With reference to FIG. 6, different codes corresponding to variousdiagnoses (or conditions) are displayed on the ICD9 search screen 6. TheICD9 search screen 6 allows the provider 10 to select a specificcondition for which the patient is requiring treatment by the provider10. Here, as shown in FIG. 6, the selection can be performed by enteringeither a CPT number or one or more keywords pertaining to the condition.With reference to FIG. 6, entering the CPT number “722” in the 1st ICD-9field 61 retrieves a list of conditions having CPT numbers starting withthe numeric string “722,” e.g., the condition “INTERVERTEBRAL DISCDISORDERS” having a CPT number of “722,” the condition “CERVICAL DISCDISPLACEMENT,” having a CPT number of “722.0,” etc.

Although FIG. 6 shows that only one numeric string is entered in thefield 61, the provider can enter additional numeric strings to selectother conditions for which the patient is also requiring treatment. Inmore detail, these additional numeric strings can be entered in the 2ndICD-9 field 62, the 3rd ICD-9 field 63, and the 4th ICD-9 field 64.Although up to four numeric strings can be entered in the embodimentshown in FIG. 6, one skilled in the art that additional fields can beimplemented such that the provider 10 can select more than fourcorresponding conditions.

With reference to FIG. 7, the condition “CERVICAL DISC DISPLACEMENT”corresponding to the CPT number 722.0 is selected. Here, a series ofquestions are presented to the provider 10 in the questions field 71 ofthe DXMEDICUS Questions screen 7. These questions may be stored in andretrieved from the DXMEDICUS filter 139 (see, for example, FIG. 1). Forexample, in FIG. 7, the question presented to the provider 10 in thequestions fields 71 is “X-ray done?” As such, the answer selectionsavailable to the provider 10 are “Yes” and “No” (selectable by clickingthe button 72 or the button 73, respectively).

In one embodiment, only one question is presented to the provider 10 inresponse to the selected condition. However, in other embodiments, aseries of more than one questions may be presented to the provider 10for each of the selected conditions. The questions in the series may ormay not be interrelated. That is, the answer provided to one of thequestions may determine whether a first sub-series of questions or asecond sub-series of questions will be presented to the provider 10.

In addition, although the buttons 72 and 73 correspond to “Yes” and“No,” respectively, in the embodiment shown in FIG. 7, one skilled inthe art can appreciate that the buttons 72, 73 can correspond to answerchoices other than merely “yes” or “no.” Further, one skilled in the artcan appreciate that questions having more than two possible answerchoices can also be implemented in the DXMEDICUS filter 139 andaccordingly displayed on the DXMEDICUS Questions screen 7.

The questions displayed in the questions field 71 are directed tosolicit information from the provider 10 for validating the diagnosisfor which the treatment is directed. That is, the questions areconfigured to elicit information from the provider 10 that would aid indetermining whether the diagnosis is medically appropriate. As such,each of the questions are questions that should be considered when theindicated diagnosis was made. The questions may be based, for example,on pieces of information collected from the international medicalliterature, which support algorithms designed to validate diagnoses. Thedisplay of the questions and prompting of a response by the medicalprovider forces the medical provider to consider these questions formore accurate diagnosis.

By way of example, a diagnosis of “Strain” or “Sprain of the LumbarRegion” (ICD 847.2) should not be made for patients who do notexperience pain in the lower back and one of the following symptoms:tenderness to palpation; limitation of range of motion in thelumbosacral spine; and swelling. In other words, if the patient does notexperience both pain in the lower back and any one of the above threesymptoms, then a diagnosis of 847.2 for this patient is incorrect.Therefore, if submitted, such a diagnosis should not be validated.Information such as that described above may be implemented in thefilters shown in FIG. 1, e.g., the DXMEDICUS filter 139.

Based upon the answers given to questions presented by the DXMEDICUSfilter 139, a diagnosis is either validated or not validated. Thisfeature of embodiments of the present invention ensures that thepatient's welfare is protected. Accordingly, the likelihood of amisdiagnosis is reduced, and the likelihood that the treatment deliveredwill help to heal the patient is increased. If the diagnosis is notvalidated, then the system may address further questions to theprovider, for example, in a formal report. Such a report may inform theprovider 10 that the answers submitted do not support a finding that thediagnosis was valid.

With reference to FIG. 8, the data entry screen 8 for a first treatmentor diagnostic procedure is displayed. Here, the system requests that theprovider 10 enter a code that corresponds to a treatment that theprovider is seeking to provide to the patient. The code may be in theform of a CPT procedure code, NDC drug code, HCPCS code, DRG code, orany other valid code for a medical service to be delivered (collectivelyreferred to as procedure codes). The procedure codes utilized mayoriginate from the fee schedule of the state or local jurisdiction inwhich the provider 10 is practicing, the AMA's CPT schedule, the HCPCS,ASA, ADA, etc. Similarly, the drug codes utilized may originate from thelist of NDC numbers that identify each and every medication found withinthe Redbook or MediCal publications, as in standard for such purposes.

In embodiments of the present invention, the provider 10 entersinformation regarding the treatment sought to be provided via the field81 (corresponding to “Procedure Code”) or the field 82 (corresponding to“Procedure Desc.”). By way of example, in the case of the field 81, theprovider 10 can enter the CPT code “97010,” which corresponds to Hot orCold Packs. In the case of the field 82, the provider can enter all orsome portion of the character string “HOT PACKS.” If the string “HOTPACKS” is entered in field 82, then the system will return all of theprocedure codes corresponding to descriptors that contain thisparticular string.

Similar to the treatment procedures described above, drug treatments canbe entered in a similar manner. By way of example, to seek validationfor administering aspirin to a patient, the provider 10 can enter theNDC number corresponding to aspirin in field 81, or enter the string“ASPIRIN” in field 82 to derive the NDC number for that particular drug.

Although only one submitted treatment is shown with reference to FIG. 8,the provider 10 can submit more than one treatment at a given time. Forexample, with reference to FIG. 9, a data entry screen 9 may be updatedto receive additional treatments or diagnostic procedures. As shown inFIG. 9, the provider can enter information regarding a second proposedtreatment or procedure in field 81′, 82′. The fields 81′, 82′ aresubstantially similar to the fields 81, 82 and, as such, will not bedescribed in more detail below.

One skilled in the art will appreciate that the system can be configuredto accept any number of treatments or diagnostic procedures that theprovider 10 wishes to submit in a manner similar to those describedabove.

After a code is entered, the engine 12 generates a series of promptsassociated with the entered code based on the filters that have beenenabled. One or more of such prompts help quantify and describe thespecific service being requested. For example, if CPT code 97010(Hot/Cold Packs) is entered as a method of treatment, the engine 12requests information that is specific to Hot/Cold Packs. The Hot/ColdPack procedure code prompts may require information regarding a daterange for rending the services, date frequency, and charges beingrequested. As another example, if a provider requests the use ofpharmaceuticals, the engine prompts for an NDC number, the number ofdoses to be dispensed, the frequency in which the drugs should be taken,number of pills to be dispensed, or the like. The answers to thequestions may then be used by the enabled filters for determining thatthe requested medical service is medically appropriate, and validatingthe requested service.

Reports generated by the system or a separate system as feedback to amedical provider upon evaluation of a submitted diagnosis and requestedmedical care will now be described in more detail with reference toFIGS. 10-11D. According to embodiments of the present invention, acomputerized medical care system may interface with a registration orbilling system to automatically generate electronic and/or hardcopydocuments including authorization information. In one embodiment, thedocument includes information that uniquely identifies the subject ofthe document.

Once the provider 10 has entered a request, the request may beelectronically transferred to a bill review engine. After the request isreceived, only those services that are pre-authorized will be paid.Because, as described previously, the preauthorization process may becompletely paperless, the process may become seamless, virtuallyeliminating the possibility of records getting lost or misdirected.

As described above, embodiments of the present invention are directed toa web-enabled, user-friendly application that allows for the entry ofprovider treatment plans. The described embodiment includes a series offilters, each of which is designed to evaluate medical treatment and theimpact of the treatment on a specific claim. For instance, one of thefilters may effectively compare the submitted procedures for a givenpatient having a certain diagnosis with the procedures historicallyprovided to other patients having the same (or substantially the samediagnosis). By way of example, if the treatment being requested isobserved in only one out of every 10,000 cases involving the samediagnosis, then the provider 10 is asked by the system to describe themedical necessity of providing the proposed treatment, in light of therare nature of that particular treatment.

One skilled in the art will appreciate that, according to an embodimentof the present invention, hundreds of different filters may beimplemented, over and above the CCI and ODG guidelines, to evaluatetreatment plans. An evaluation is made, using artificial intelligencewith little to no human decision-making. The response of the system maybe nearly instantaneous in notifying the provider regarding the proposedtreatment plan.

For example, the system may submit an email to the provider 10 withinten seconds, either authorizing care or raising questions that requireadditional information from the provider 10 before authorization can begranted. That is, embodiments of the present invention are designed toeither authorize a submitted procedure or obtain information from theprovider 10 that would demonstrate the medical necessity of theprocedure being submitted for the condition being treated. If theprovider 10 is unable to provide the necessary additional information,then authorization is not granted for performing the procedure.

FIG. 10 is a screen capture of a reporting interface according to oneembodiment of the invention. The interface includes a “create response”icon 100 which is actuated for generating a letter that is responsive toa pre-approval request.

FIGS. 11A-11C is an example of a response letter produced upon actuationof the “create response” icon 100 according to one embodiment of theinvention. As shown in FIGS. 11A-11C, a provider has requestedauthorization to perform two procedures: “SURGERY NERVOUS SYSTEM SPINEAND SPINAL CORD LAMINOTOMY WITH DECOMPRESSION OF NERVE ROOTS INCLUDINGPARTIAL FACETECTOMY FORAMINOTOMY AND OR EXCISION OF HERNIATEDINTERVERTEBRAL DISK ONE INTERSPACE LUM” (corresponding to a CPT Code of63030) and “EVALUATION AND MANAGEMENT OFFICE OR OUTPATIENT VISIT NEWPATIENT WITH DETAILED PROBLEM FOCUSED HISTORY EXAMINER DECISION MAKINGOF LOW COMPLEXITY 30 MINUTES” (corresponding to a CPT Code of 99203). Asalso shown in FIGS. 11A-11C, the provider requested a fee of $5000 forthe first procedure and a fee of $200 for the second procedure.

With further reference to FIGS. 11A-11C, the system responds to theprovider's request. Here, the system authorized the procedures becausethe provider satisfied the criteria (as implemented, for example, in oneor more filters, with reference to FIG. 1) demonstrating the medicalnecessity of the diagnosis, and the system confirmed the validity of thediagnosis determined by the provider. In addition, the system performedan analysis of the fees proposed by the provider in view of allowancesset forth by one or more groups of industry standards. For example, theallowances may arise from California's Official Medical Fee Schedule N(OMFS). As another example, as shown in FIGS. 11A-11C, the allowancesmay arise from the Official Medical Fee Schedule (OMFA) of theCalifornia Workers' Compensation Division of Industrial Injuries andestablished by the Administrative Director of the Division, pursuant toSections 5307.1 and 5307.3 of the California Labor Codes.

With continued reference to FIGS. 11A-11C, because the fees proposed bythe provider exceeded the identified allowances (i.e., an allowance of$994.47 for the procedure corresponding to CPT 63030 and an allowance of$102.37 for the procedure corresponding to CPT 99203), the systemauthorizes payments in amounts consistent with the allowances. Inaddition, it also offers the provider an opportunity to disclose anyservices that it has rendered that may go beyond the services typicallyassociated with the submitted procedure. Here, if the provider is ableto supply such information, which supports authorization of furtherpayment(s), then the provider may do so.

FIG. 11D is an example letter generated as feedback to a medicalprovider with respect to multiple submitted diagnoses. The letterindicates that the responses to the questions that were displayed by theengine are not consistent with answers that would validate thediagnoses. According to one embodiment of the invention, the letter maybe accompanied with journal articles that were used in framing thequestions that were asked. The letter further requests that the medicalprovider provide additional medical information used in making thediagnoses, allowing the medical provider to defend the diagnoses thatwere made.

According to one embodiment of the invention, a letter that fails tovalidate a diagnosis or requested medical service is configured toprompt modification of the diagnosis or medical service that isultimately rendered to a patient. In this manner, any errors made by themedical provider is corrected before the requested medical service isactually rendered to the patient.

Any of the filters described herein can either be turned on or off,based upon a client's specifications. Additionally, the several hundredfilters associated with Medata's CORE filters 131 can also be turned onor off either individually or as a group or two or more of the filters.

FIG. 12 is a flow diagram of a pre-approval process executed by theengine 12 according to one embodiment of the invention. The process maybe implemented by a processor hosted by the engine 12 according tocomputer program instructions stored in a memory that is coupled to theprocessor. The steps in the process may be executed in the order shown,or in any other order that will be appreciated by a person of skill inthe art

The process starts with a requesting device (e.g. the medical provider10 or client case manager 15) initiating a pre-approval session. In step80, the engine receives one or more diagnosis codes from the requestingdevice. Each code may be entered via a graphical user interface such asthe one illustrated in FIG. 6.

In step 81, the engine identifies the enabled diagnosis filter (e.g. theD×Medicus Filter 139).

In step 82, the engine applies the enabled diagnosis filter for thereceived diagnosis code(s).

In step 83, a determination is made as to the validity of the diagnosisbased on the applied medical diagnosis filter. In this regard, theengine determines whether the submitted diagnosis is medicallyappropriate based on information gathered from experts in the medicalfield, medical literature and research, and the like.

If the diagnosis is medically appropriate, the diagnosis is deemed validin step 85. Otherwise, the diagnosis is deemed invalid in step 84.

In step 86, the engine receives a service code(s) identifying arequested medical service(s). The service code may be entered via agraphical user interface such as the one illustrated in FIG. 8. Otherconditions relating to the rendering of the service may also be enteredvia the graphic user interface illustrated in FIG. 8.

In step 87, the engine identifies one or more enabled medical procedurefilters. Such filters may include, for example, filters 131-138illustrated in FIG. 1.

In step 88, the engine applies each of the procedure filters for thereceived service code.

In step 89, a determination is made as to the validity of the requestedmedical service relative to the diagnosis that was made based on each ofthe applied medical procedure filters. In this regard, the enginedetermines whether the requested service or a condition relating to theservice is medically appropriate in light of the diagnosis that wasmade.

If the requested service is medically appropriate, the service is deemedvalid in step 91. Otherwise, the diagnosis is deemed invalid in step 90.

After the validity of the diagnosis and requested services aredetermined during the pre-approval session, the engine proceeds toprovide feedback to the requesting device of the determination.According to one embodiment of the invention, the feedback is providedduring the pre-approval session, substantially contemporaneous with thevalidity determinations. The feedback may be in the form of a letteraddressed to the medical service provider which is generated anddisplayed upon selection of the create response icon 100 (FIG. 10). Theletter may also be emailed to the medical service provider ortransmitted via any other data communications medium as may beconventional in the art. The instant feedback to the medical serviceprovider prompts the on-the-spot adjustment by the provider of thediagnosis and/or medical service to be rendered, resulting in improvedand more efficient service and care for the patients.

Below are more detailed descriptions of the filters supported by thecomputerized medical care system according to one embodiment of theinvention.

Organization Based Filters

According to one embodiment of the invention, a plurality of filters areprovided under an organizational category for implementing rules,suggestions, and protocols by organizations such as, for example, ACOEM,medical societies, specialty groups, chiropractic organizations,osteopathic organizations, the Federal Government, and the like, whichcontrol the delivery of medical care. The rules and suggestions by theseorganizations are valuable and frequently followed as guidelines forappropriate medical care. According to one embodiment, every rule, andsuggestion, found in these publications are incorporated into one ormore filters provided by the computerized medical care system as rulesand suggestions that should be followed by medical practitionerstreating patients.

FIG. 13 is a screen capture of a screen listing various organizationsthat a user may select in order to enable filters associated with theselected organizations according to one embodiment of the invention.

ACOEM

One exemplary organizational filter provided by the computerized medicalcare system is an ACOEM filter, which incorporates rules that wereestablished by the American College of Occupational and EnvironmentalMedicine (ACOEM), 2^(nd) Edition. All the applicable rules in Chapters 8through 14 which applies to information contained within the publicationrelative to the appropriate treatments and procedures for workers'compensation/industrial injuries are implemented by the ACOEM filter.

The State of California adopted the ACOEM guidelines as part of theCalifornia Code of Regulations, Chapter 4.5 Division of Workers'Compensation, Subchapter 1. Administrative Director-AdministrativeRules, Article 5.5.2 Medical treatment utilization schedule, §9793.21Medical Treatment Utilization Schedule, (a)(1)(http://www.dir.ca.gov/t8/9792_(—)21.hmt.).

More than one hundred rules that were created by the Association arevalid measures for appropriate medical care for various medicalinjuries. These rules are implemented by the ACOEM filter for beingapplied to procedure codes in the Current Procedural Terminology (CPT)and diagnostic codes as listed within the International Classificationof Diseases, Revision 9 (ICD-9).

For example, a Chiropractor may request to perform chiropracticmanipulation for a workers' compensation patient with a neck sprain 3months after the date of injury. The computer software then queries thesystem to analyze whether the procedure is appropriate for thecondition, and whether the procedure is appropriate in the time framethe services are rendered. On page 181 of the ACOEM Guidelines is foundthe following information in Table 8-8:

TABLE 8-8 Summary of Recommendations for Evaluating and Managing Neckand Upper Back Complaints Clinical Measure Recommended Optional NotRecommended Physical Physical Traction (B) treatment manipulation forTENS (C) methods neck pain early in Other Modalities care only (B) (D)″At-home applications of heat or cold (D) Radio-frequency neurotomy (C)

Since the request for manipulation from the provider is made late in thetherapeutic period, there really is no apparent justification for theproposed therapy. This therapy is optional ONLY if performed “early incare”. Therefore, the engine 12 is configured to send an email to theprovider requesting additional information which could justify themedical necessity for therapy that is unsupported by the ACOEMguideline.

Correct Coding Initiative (CCI)

Another organizational filter provided by the computerized medical caresystem is a Correct Coding Initiative (CCI) filter. The CCI edits werecreated by the Federal government to promote national correct codingmethodologies and to control improper coding leading to inappropriatepayment in Part B claims. These edits were developed utilizing codingpolicies based on coding conventions defined in the American MedicalAssociation's CPT Manual, national and local policies and edits, codingguidelines developed by national societies, analysis of standard medicaland surgical practices, and a review of current coding practices.

The CCI filter applies these rule sets to prevent improper payment whenincorrect code combinations are reported. There are approximately440,000 separate CCI edits used by the CCI filter. Below is adescription of a few of those edits:

Column 1 Column 2 CCI INSTRUCTIONS 13151 13153 Pay 13151 and Deny 1315320000 20005 Pay 20000 and Deny 20005 30000 30020 Pay 30000 and Deny30020 71260 36000 Pay 71260 and Deny 36000 86890 99203 Pay 86890 andDeny 99203 99203 43752 Pay 99203 and Deny 43752 etc.

For example, the above information means that procedures 13151 and 13153are an improper coding combination. In this specific case, procedurecode 13153 should not be allowed.

Osteopathic Initiative

Another organizational filter provided by the computerized medical caresystem is an AOA filter. The American Osteopathic Association (AOA)publishes an initiative which provides osteopathic physicians withappropriate guidelines. According to one embodiment of the invention,all the AOA guidelines are applied by the AOA filter.

Chiropractic Initiative

A further organizational filter provided by the computerized medicalcare system is an ACA filter. The American Chiropractic Association(ACA) publishes an initiative which provides chiropractic physicianswith appropriate guidelines. According to one embodiment of theinvention, all the AOA guidelines are applied by the AOA filter.

Medicare Allowance

Another organizational filter provided by the computerized medical caresystem is a Medicare allowance filter. The Medicare allowance filterapplies Medicare allowance recommendations consistent with a RBRVSmethod of payment. The RBRVS method of payment includes variablesrelated to the following formula:

[((RVUW×Budget Neutrality CF)×RVZW)+(RVUE×RVZE)+(RVUP×RVZP)]×CF

where each variable is defined as follows:

-   -   RVUW=Physician's WORK relative value units assigned to the        procedure code    -   RVUE=Physician's EXPENSE relative value units assigned to the        procedure code    -   RVUP=Physician's MALPRACTICE relative value units assigned to        the procedure code    -   RVZW=Geographic WORK relative value units assigned to the        provider's Medicare Locality    -   RVZE=Geographic EXPENSE relative value units assigned to the        provider's Medicare Locality    -   RVZP=Geographic MALPRACTICE relative value units assigned to the        provider's Medicare Locality    -   CF=Medicare Conversion Factor

If the provider submits an invoice for an amount greater than thatmandated by Medicare, then the provider is notified of this fact priorto the services being rendered. This is important to the provider and tothe user, in that it clarifies cost considerations in the delivery ofmedical services and prior to those services being rendered.

Disability Analysis

Another organizational filter provided by the computerized medical caresystem is a disability analysis filter based on guidelines provided by“The Official Disability Guidelines (ODG)” which is published by WorkLoss Data Institute (WLDI). The ODG contains lost time guidelines basedupon actual data as opposed to expert opinion. For example, if a patientis placed on disability that far exceeds those experienced by otherpatients treated for the same condition, the disability analysis filterapplies the real world example and requests an explanation from theprovider for the necessity for the prolonged disability. The systemprovides a communication to the provider requesting specific informationto justify the prolonged disability.

DRG

Another filter provided by the computerized medical care system is aCorrect Coding Initiative (CCI) filter. The Diagnosis Related Group(DRG) system was designed by the Federal Government to control runawaycharges for inpatient hospitalization. It was originally proposed in theearly 1980's and has been accepted universally for Medicare.Additionally, many state agencies have implemented a DRG method ofreimbursement for inpatient hospital stays. Currently, 14 states utilizemodified DRG systems to control costs. According to one embodiment, allof the DRG information is included in the DRG filter. For example, ahospital provider recommending a patient for hospitalization is notifiedbefore being hospitalized of the DRG allowance for the condition forwhich the patient is being hospitalized. In addition to the allowance,the system notifies the provider of the DRG utilized and request theprovider submit information justifying the additional charges.

DxMedicus

The DXMEDICUS filter provides a graphical user interface that allowsmedical providers, or claims handlers taking calls from the providers,to enter diagnostic information (ICD-9 codes) into the engine 12. TheDXMEDICUS filter prompts the user with a series of questions based onthe provider's diagnosis. Each of the questions are questions thatshould be considered whenever a particular diagnosis is made.

Each of the diagnoses in the ICD-9 that are used in indemnity and othertypes of cases have been formalized to form a computerized algorithmwhich either confirms or questions the validity of the diagnosis.According to one embodiment, the DXMEDICUS algorithms do not make adiagnosis, but rather, validates or invalidates the provider'sdiagnosis.

FIG. 14A is a more detailed flow diagram of step 82 (FIG. 12) ofapplying the DXMEDICUS filter 139 for validating a medical diagnosisaccording to one embodiment of the invention.

In step 110, the filter displays a question that should be considered inmaking the diagnosis of the medical condition. In this regard, thefilter identifies the specific diagnosis code and retrieves thequestions that have been correlated to the code from the database 140.

In step 112, the filter prompts a user response to the displayedquestion as is illustrated in FIG. 7.

In step 114, the filter compares the expected response with the enteredresponse. In this regard, the filter retrieves the expected answers thathave been stored in the database 140 for each displayed question for thespecific diagnosis.

If there is a match, as is determined in step 116, the diagnosis isvalidated in step 120. Otherwise, the diagnosis is not validated in step118, and materials supporting the lack of validation may be optionallyretrieved from the database 140 and provided to the medical serviceprovider along with a response letter. That is, if the providerquestions the decision of the DXMEDICUS filter, the system is configuredto retrieve journal articles on the diagnosis in question, and transmitthose articles to the medical provider via, for example, email, andfurther request that the medical provider submit articles that supporthis contention.

According to one embodiment of the invention, a medical provider'sresponses to the displayed prompts are recorded and stored in ahistorical database maintained in the database for future reference, asis reflected in step 122. Such information may be correlated to specificpatients to which the requests relate, specific doctors making thediagnosis and request, and the like.

In step 124, a letter may be optionally generated indicating that thediagnosis has been validated or not. According to another embodiment,unlike the other filters within the system, the DXMEDICUS filter doesnot authorize or request additional information from the provider. Thevalidation or lack thereof is stored in the historical database forlater generating of reports based on a user command.

FIG. 14B is a flow diagram of a process for validating a specificdiagnosis code, ICD-9 code 850.0, according to one embodiment of theinvention. ICD-9 code 850.0 is defined as “concussion with no loss ofconsciousness.” In step 200, receipt of this specific ICD-9 code promptsdisplay of a question as to whether there was head trauma. If theresponse to the question is YES, a question is displayed in step 202 asto whether there was loss of consciousness. If the answer is YES, theentered ICD-9 code is verified in step 204. If the response to eitherthe question of head trauma or loss of consciousness is negative, theICD-9 code is not verified, as reflected by steps 206 and 208. In otherwords, in the absence of head trauma and/or loss of consciousness, ICD-9diagnosis code 850.0 is deemed not valid.

History Based Filters

According to one embodiment of the invention, a plurality of filters areprovided under a historical category which validate procedures based onanalysis of historical data. In this regard, the computerized medicalcare system is configured to maintain the history of diagnoses andservices that are rendered on a patent-by-patient basis in thehistorical database, as well as information on procedures and/orservices rendered historically for each type of diagnoses.

FIG. 15 is a screen capture of a graphical user interface listingvarious history based filters that may be enabled by a user according toone embodiment of the invention. Such history based filters include, butare not limited to a heat filter, rarity filter, level of servicefilter, prevailing billing practices filter, number of visits filter,duration of care filter, previous history analysis filter, TAL allowancefilter, and charges per case filter.

FIG. 16 is a generalized flow diagram of step 88 (FIG. 12) for applyingat least some of the history based filters according to one embodimentof the invention.

In this regard, a specific historical filter that has been enabled isinvoked in step 300 by the engine.

In step 302, historical data collected for the service code and/orconditions in which the identified medical service were rendered areretrieved from the historical database.

In step 304, the historical data is analyzed based on the invokedhistorical filter. This analysis may include, for example, determining apercentile distribution of the service code or of the conditions inwhich the identified service was rendered.

Based on the analysis of the historical data, a determination is made instep 306 as to whether the requested medical service is statisticallyreasonable. In this regard, the system may be configured with areasonableness threshold, which, according to one embodiment of theinvention, is selected by an administrator of the system. The selectedreasonableness threshold may identify, for example, a thresholdpercentage value.

In making the determination of whether the requested service isstatistically reasonable, a determination is made as to whether therequested service or condition surrounding the rendering of therequested service satisfies the threshold percentage value according tothe analyzed percentage distribution data.

If the requested service is deemed to be statistically reasonable, thefilter returns a result indicating that the requested service may bevalidated in step 310. Otherwise, the filter returns a resultingindicating that the requested service may not be validated in step 308.

Heat

According to one embodiment of the invention, the heat filter utilizeshistorical data to determine the appropriate use of heat-based physicaltherapy modalities on soft tissue injuries.

Soft tissue injuries, by nature, normally resolve within six to eightweeks from the date of injury. During this time, the conditions areconsidered to be in an “acute” phase. Inflammation, and the associatedfindings, characterize the conditions during this period. Therefore, thetherapeutic goal in this time frame is to ameliorate the inflammationthat is associated with the conditions. If the conditions do not resolvewithin this period, and remain symptomatic, then the conditions areconsidered to have progressed to a more chronic phase. The therapeuticgoal of the chronic phase is to recondition and rehabilitate the patientto recover lost functions which can be responsible for the continuedsymptoms, and the failure to achieve full recovery.

The continued usage of these acute type therapies into the period whenthese injuries are chronic would afford this patient no therapeuticbenefit. For example, for a patient that was injured on Feb. 1, 2008,physical therapy modalities (procedures 97010, 97012, 97014, etc.) wouldprobably be of benefit if delivered prior to Mar. 15, 2008. Any of thesemodalities delivered after Mar. 15, 2008, are usually inappropriate ifthe patient's condition has moved to a more chronic phase. Thus, if theservices being requested are being rendered subsequent to Mar. 15, 2008,the system is configured to generate and transmit a letter asking theprovider to submit information which would support the medical necessityfor care that is normally unnecessary in that time frame.

FIG. 17 is a flow diagram of step 88 (FIG. 12) for applying a heatfilter according to one embodiment of the invention. In step 400, theheat filter is invoked by the engine.

In step 402, the filter identifies a date of injury for which theheat-based physical therapy modality would be applied. This informationmay be provided by the medical service provider, for example, whenentering the service code for the requested medical service.

In step 404, the timing of the heat-based physical therapy isidentified.

In step 406, a determination is made as to whether the timing isappropriate. In this regard, the filter may compute a number of daysfrom the date of the injury to the timing of the therapy, compare thenumber of days to a threshold number of days, and determine that thetherapy is appropriate if the calculated number of days is within thethreshold. The threshold number of days may be determined, for example,based on medical guidelines enabled for the system.

If the medical service is deemed to be appropriate, the filter returns aresult indicating that the requested service may be validated in step408. Otherwise, the filter returns a resulting indicating that therequested service may not be validated in step 410.

Rarity

Rarity is another filter which utilizes a database for determining therelatedness of a CPT code to the ICD-9 code. According to oneembodiment, a rarity database which may form part of the database 140 isderived from over 700 million provider charges throughout the UnitedStates. The analysis of these charges determines the ratio between thenumber of times a specific procedure is performed for a specific ICD-9diagnosis, as compared to all other procedures performed by all otherproviders billing for the same diagnosis.

Clients who utilize the rarity filter are able to determine a rarityratio, that is, a threshold, that defines whether or not a CPT code isdeemed rare for the submitted ICD-9. Although the ratio is statisticallyvalid, it should not be applied arbitrarily. Therefore, when a proposedtreatment is requested and falls outside the ratio, the provider isgiven every opportunity to justify the medical necessity for performingthe procedure, in spite of the fact it is rarely performed for thatdiagnosis.

For example, in indemnity cases, CPT code 97010 (Hot/Cold Packs)accounts for one out of every ten procedures performed for ICD-9 code847.2 (Lumbar Sprain/Strain) according to the data in the raritydatabase. The ratio for this procedure is one out of every ten.Therefore, it should not be considered rarely performed. On the otherhand, analysis of the rarity database may indicate that CPT code 63030(Lumbar Laminectomy) for ICD-9 code 847.2 (Lumbar Sprain/Strain)occurred only six times in 2,000,000 claims. This procedure is shouldtherefore deemed to be rare.

FIG. 18 is a flow diagram of step 88 (FIG. 12) for applying a rarityfilter according to one embodiment of the invention. In this regard, instep 450, the rarity filter is invoked by the engine.

In step 452, the filter retrieves historical data from the raritydatabase of medical services provided for the identified diagnosis code.

In step 454, the filter analyzes the historical data to identify a ratein which the requested medical service was provided for the identifieddiagnosis code.

In step 456, a threshold rate is identified. In this regard, a systemadministrator may set a reasonable threshold rate that should be met ifa procedure is not to be deemed to be rare.

In step 458, the filter determines if the threshold is satisfied bycomparing the identified rate for the requested medical service againstthe threshold rate.

If the threshold is satisfied, the filter returns a result indicatingthat the requested service may be validated in step 462. Otherwise, thefilter returns a resulting indicating that the requested service may notbe validated in step 460.

Level of Service

Services necessary to satisfy the patient's needs are generally notconstant but variable. For example, the Current Procedural Terminology(CPT) defines the Evaluation & Management procedures as follows:

NEW PATIENT CODE Description 99201 Office or other outpatient visit forthe evaluation and management of a new patient, which requires these 3key components A problem focused history A problem focused examinationStraightforward medical decision making Counseling and/or coordinationof care with other providers or agencies are provided consistent withthe nature of the problem(s) and the patient's and/or family's needs.Usually, the presenting problem(s) are self limited or minor. Physicianstypically spend 10 minutes face-to-face with the patient and/or family.99202 Office or other outpatient visit for the evaluation and managementof a new patient, which requires these 3 key components An expandedproblem focused history An expanded problem focused examinationStraightforward medical decision making Counseling and/or coordinationof care with other providers or agencies are provided consistent withthe nature of the problem(s) and the patient's and/or family's needs.Usually, the presenting problem(s) are self limited or minor. Physicianstypically spend 20 minutes face-to-face with the patient and/or family.99203 Office or other outpatient visit for the evaluation and managementof a new patient, which requires these 3 key components A detailedhistory A detailed examination Medical decision making of low complexityCounseling and/or coordination of care with other providers or agenciesare provided consistent with the nature of the problem(s) and thepatient's and/or family's needs. Usually, the presenting problem(s) areself limited or minor. Physicians typically spend 30 minutesface-to-face with the patient and/or family. 99204 Office or otheroutpatient visit for the evaluation and management of a new patient,which requires these 3 key components A comprehensive history Acomprehensive examination Medical decision making of moderate complexityCounseling and/or coordination of care with other providers or agenciesare provided consistent with the nature of the problem(s) and thepatient's and/or family's needs. Usually, the presenting problem(s) areself limited or minor. Physicians typically spend 45 minutesface-to-face with the patient and/or family. 99205 Office or otheroutpatient visit for the evaluation and management of a new patient,which requires these 3 key components A comprehensive history Acomprehensive examination Medical decision making of high complexityCounseling and/or coordination of care with other providers or agenciesare provided consistent with the nature of the problem(s) and thepatient's and/or family's needs. Usually, the presenting problem(s) areself limited or minor. Physicians typically spend 60 minutesface-to-face with the patient and/or family.

ESTABLISHED PATIENT CODE Description 99211 Office or other outpatientvisit for the evaluation and management of an established patient, thatmay not require the presence of a physician. Usually, the presentingproblem(s) are minimal. Typically, 6 minutes are spent performing orsupervising these services. 99212 Office or other outpatient visit forthe evaluation and management of an established patient, which requiresat least 2 of these 3 key components An problem focused history; Anproblem focused examination; Straightforward medical decision making.Counseling and/or coordination of care with other providers or agenciesare provided consistent with the nature of the problem(s) and thepatient's and/or family's needs. Usually, the presenting problem(s) areself limited or minor. Physicians typically spend 10 minutesface-to-face with the patient and/or family. 99213 Office or otheroutpatient visit for the evaluation and management of a new patient,which requires at least 2 of these 3 key components An expanded problemfocused history; An expanded problem focused examination; Medicaldecision making of low complexity. Counseling and/or coordination ofcare with other providers or agencies are provided consistent with thenature of the problem(s) and the patient's and/or family's needs.Usually, the presenting problem(s) are self limited or minor. Physicianstypically spend 15 minutes face-to-face with the patient and/or family.99214 Office or other outpatient visit for the evaluation and managementof a new patient, which requires at least 2 of these 3 key components Adetailed history A detailed examination Medical decision making ofmoderate complexity Counseling and/or coordination of care with otherproviders or agencies are provided consistent with the nature of theproblem(s) and the patient's and/or family's needs. Usually, thepresenting problem(s) are self limited or minor. Physicians typicallyspend 25 minutes face-to-face with the patient and/or family. 99215Office or other outpatient visit for the evaluation and management of anew patient, which requires at least 2 of these 3 key components Acomprehensive history A comprehensive examination Medical decisionmaking of high complexity Counseling and/or coordination of care withother providers or agencies are provided consistent with the nature ofthe problem(s) and the patient's and/or family's needs. Usually, thepresenting problem(s) are self limited or minor. Physicians typicallyspend 40 minutes face-to-face with the patient and/or family.

According to one embodiment of the invention, billings from thehistorical database are reviewed to determine the appropriate level ofservice (LOS) for each of the International Classification ofDisease—Revision 9 (ICD-9) codes. In this regard, based on the analysisof the bills, a determination is made as to the level of service that ismost frequently used for each of the diagnoses. For example, review ofthe historical data may indicate that patients with sprains of the neckmost frequently use a level equal to, or less than, 99202 for initialvisits, and 99212 for subsequent visits. Therefore, any time a providermakes a request for a level of service in excess of those codes for thisdiagnosis, the system automatically generates a request for additionalinformation that medically justifies the greater level of service beingrequested.

FIG. 19 is a flow diagram of step 88 (FIG. 12) for applying a level ofservice filter according to one embodiment of the invention. In thisregard, in step 550, the level of service filter is invoked by theengine.

In step 552, the filter identifies a level of service associated withthe identified service code.

In step 554, the filter retrieves and analyzes historical data ofprevious level of services provided for the identified diagnosis code.For example, the historical data may provide a percentage distributionfor the different levels of services for the identified diagnosis code.

In step 556, the filter identifies a threshold level of service based onthe analyzed historical data. For example, the filter may identify alevel of service that has historically been rendered 90% of the time inwhich the particular diagnosis was made.

In step 558, a determination is made as to whether the threshold hasbeen satisfied. That is, the filter determines whether the identifiedlevel of service is at or below the threshold level of service.According to one embodiment of the invention, the level of servicesincrease with an increase in the associated service code. Thus, a levelof service having code “99201” is deemed to be lower than a level ofservice having code “99202.”

If the threshold is satisfied, the filter returns a result indicatingthat the requested service may be validated in step 562. Otherwise, thefilter returns a resulting indicating that the requested service may notbe validated in step 560.

Prevailing Billing Guidelines

According to one embodiment of the invention, analysis of historicmedical provider billings yields information regarding how providersbill under normal circumstances. Prevailing billing guidelines may bederived from such analysis. The billing guidelines may cover a varietyof different billing circumstances. Exemplary billing guidelinesinclude:

a. The prevailing billing guideline for assistant surgeon fees is 20% ofthe surgeon's fee.

b. The prevailing billing guideline for surgeons performing severalprocedures at the same time, during the same session, is to charge thefull amount for the primary procedure and charge 50% for all subsequentprocedures performed during the same session.

c. Another prevailing billing guideline for certain surgery proceduresis to include related services for the same diagnosis under the initialsurgical procedure. This finding is important for deriving informationabout bundling and unbundling.

d. The charge for an examination of a patient is included in the chargefor the major surgical procedure performed on the same day.

e. The charge for the major surgical procedure includes the servicesrendered subsequently for the condition for which the surgery wasperformed. This is referred to in peer review departments as the FollowUp Day (FUD) rule.

f. The charge for an initial/subsequent visit for a patient receivingphysical therapy care is included in the value of the charges for thephysical therapy session.

g. All radiology procedures contain inherent restrictions regarding thenumber of views taken. For example, a complete lumbar spine examinationrequires at least 4 views. A provider performing 3 views for a completelumbar study is short 1 view and should be paid for a limited study.

h. The prevailing billing guideline for automated pathologicalprocedures using computerized Sequential Multi-channel Analysis (SMA)have a single charge for the procedures. Too often, providers willcharge as if these procedures were manually performed separately. Thislatter practice is not prevailing and probably hinges upon fraud.

FIG. 20 is a flow diagram of step 88 (FIG. 12) for applying a billingguidelines filter according to one embodiment of the invention. In thisregard, in step 600, the billing guidelines filter is invoked by theengine.

In step 602, the filter receives a requested charge amount. For example,the amount may be entered by the medical service provider when enteringthe service code for the requested medical service.

In step 604, the filter analyzes the billing guideline for the requestedmedical service.

In step 606, a determination is made as to whether the billing guidelineis satisfied. If the answer is YES, the filter returns a resultindicating that the requested service may be validated in step 608.Otherwise, the filter returns a resulting indicating that the requestedservice may not be validated in step 610.

Number of Visits

According to one embodiment of the invention, the system includesvarious utilization filters 138 including a number of visits filter.This particular filter evaluates the percentile distribution of thenumber of visits claimants have been seen for various ICD-9 codes. Forexample, the following chart will distribute the number of visits seenfor ICD-9 code 847.0 in approximately 200,000 claims:

Percentile 50th 55th 60th 65th 70th 75th 80th 85th 90th 95th Visits 4 56 7 8 10 15 16 18 35

The client can select the percentile which they elect to use as being“the reasonable” value. The system stores the above information, plusthe values for the 99^(th) percentile as well. If the client selects the80^(th) percentile as being a reasonable number of visits, as based uponthe analyzed history, then 15 visits is considered reasonable. Visits inexcess of 15 would require some additional explanation from the providerindicating the medical necessity for the prolonged care.

Duration of Care

Another utilization filter 138 according to one embodiment of theinvention is a duration of care filter. This particular filter evaluatesthe percentile distribution of duration of care for claimants who havebeen seen for various ICD-9 codes. For example, the following chart willdistribute the duration of care for ICD-9 code 847.0 in approximately2,000,000 claims:

Percentile 50th 55th 60th 65th 70th 75th 80th 85th 90th 95th Duration 3243 56 68 8 80 93 109 132 253

As with the number of visits filter, the client can select thepercentile which they elect to use as being “the reasonable” value. Thesystem stores the above information, plus the values for the 99^(th)percentile as well. If the client selects the 80^(th) percentile asbeing a reasonable duration of care, as based upon the analyzed history,then 109 days would be considered reasonable. Duration of care exceeding109 days would require some additional explanation from the providerindicating the medical necessity for the prolonged care.

FIG. 21 is a flow diagram of step 88 (FIG. 12) for applying autilization filter according to one embodiment of the invention. In thisregard, in step 500, the utilization filter is invoked by the engine.

In step 502, the filter receives information on a requested number ofvisits or duration of care for the identified service code. For example,this information may be entered by the medical service provider whenentering the service code for the requested medical service.

In step 504, the filter retrieves and analyzes historical data ofprevious number of visits or duration of care provided for theidentified diagnosis code. This analysis may include, for example,determining a percentile distribution of the number of visits orduration of care for the identified diagnosis code.

In step 506, a threshold percentile value is identified. According toone embodiment of the invention, the threshold percentile value may beset by a system administrator. Based on this threshold percentile value,a threshold number of visits or duration of care may be identified fromthe historical data.

In step 508, a determination is made as to whether the threshold valuehas been satisfied. In this regard, the filter determines whether theindicated number of visits or duration of care is not more than thethreshold number of visits or duration of care.

If the answer is YES, the filter returns a result indicating that therequested service may be validated in step 512. Otherwise, the filterreturns a resulting indicating that the requested service may not bevalidated in step 510.

Previous History Analysis

According to one embodiment of the invention, the system also includes apatient history filter which analyzes the patient's previous history inorder to determine the appropriateness and validity of the care. Forexample, a patient with a previous amputation of the right thumb wouldnot be a good candidate for an amputation of the right thumb.Furthermore, a patient who already has had an appendectomy would notneed another.

According to one embodiment of the invention, the system maintains ahistory of all previous care that has been rendered to a specificpatient for the current condition. The system further collectsinformation on what has worked successfully for previous patients andwhat has not. This helps to prevent treating a patient with a modalitythat has no therapeutic benefit.

FIG. 22 is a flow diagram of step 88 (FIG. 12) for applying a patienthistory filter according to one embodiment of the invention. In thisregard, in step 700, the patient history filter is invoked by theengine.

In step 702, the filter identifies a specific patient for whichpre-approval is being requested.

In step 704, the filter retrieves and analyzes historical data collectedfor the specific patient. In this regard, the filter may retrieve andanalyze data on previous medical services provided for the specificmedical condition that has currently been diagnosed.

In step 706, a determination is made as to whether the requested medicalservice is adequate 706. In this regard, the filter may determinewhether a requested medical service is one that should not be repeatedtwice on a particular body part, within a certain period of time, or thelike.

If the requested medical service is adequate, the filter returns aresult indicating that the requested service may be validated in step710. Otherwise, the filter returns a resulting indicating that therequested service may not be validated in step 708.

TAL Allowance

According to one embodiment of the invention, a TAL filter is used todetermine the reasonableness of a procedure or service when there is nota value already designated by a fee schedule, or a contracted rate.According to one embodiment, unlike other “usual & customary” chargesdatabases, the charges used by the TAL filter are derived from actualprovider charges. In other words, every specific value in the TALdatabase may be supported by information that was used to create thatvalue. The value may be traced to a specific provider's charge for aprocedure performed for a specific patient on a specific date on aspecific billing. For example, one of the charges that may contribute tothe value used by the TAL filter was performed by Dr. Jones on patientSmith on Oct. 22, 2006 on billings submitted to ABC Insurance Company onNov. 30, 2006. This audit trail can help prove the validity of thereasonableness value of the procedure allowance.

Total Charges per Case

According to one embodiment of the invention, the system furtherincludes a “Total Claim Charges” filter. This particular filterevaluates the percentile distribution of total claim cost for claimantswho have been seen for various ICD-9 codes. For example, the followingchart will distribute the total claim cost for ICD-9 code 847.0 inapproximately 2,000,000 claims:

Percentile 50th 60th 70th 80th 90th 95th PI Total Charges 2,230.002,950.00 3,980.00 5,846.00 9,630.00 14,697.38 WC Total Charges 1,045.241,630.38 2,666.37 4,849.90 12,229.89 27,927.59

The system stores the above information, plus the values for the55^(th), 65^(th), 75^(th) 85^(th) and 99^(th) percentiles as well. ForPersonal Injury (PI), the above data shows that 80% of 384,840 claimswhich share the ICD-9 code 847.0 had total charges of $5,846.00 or lessand only 20% had charges in excess of this amount. For Workers'Compensation (WC), the above data shows that 80% of 65,112 claims whichshare the ICD-9 code 847.0 had total charges of $4,849.90 or less andonly 20% had charges in excess of this amount.

According to one embodiment, a system administrator may select thepercentile that is deemed to be a reasonable value. If the systemadministrator selects the 80^(th) percentile as being a reasonableamount for total claim charges, as based upon the analyzed history, thena total claim charge of $5,846.00 would be considered reasonable for PIcases, while $4,849.90 would be considered reasonable for WC cases.Visits in excess of 15 would require some additional explanation fromthe provider indicating the medical necessity for the prolonged care.

FIG. 23 is a flow diagram of step 88 (FIG. 12) for applying a chargesfilter according to one embodiment of the invention. In this regard, instep 650, the charges filter is invoked by the engine.

In step 652, the filter receives a requested charge amount. For example,this information may be entered by the medical service provider whenentering the service code for the requested medical service.

In step 654, the filter retrieves and analyzes historical data ofcharges made for the identified diagnosis code. This analysis mayinclude, for example, determining a percentile distribution of thecharges for the identified diagnosis code based on the historical datain the historical database.

In step 656, a threshold percentile value is identified. According toone embodiment of the invention, the threshold percentile value may beset by a system administrator. Based on this threshold percentile value,a threshold charge amount may be identified from the historical data.

In step 658, a determination is made as to whether the threshold valuehas been satisfied. In this regard, the filter determines whether theindicated charge is not more than the threshold charge amount.

If the answer is YES, the filter returns a result indicating that therequested service may be validated in step 662. Otherwise, the filterreturns a resulting indicating that the requested service may not bevalidated in step 660.

State Workers' Compensation Filters

According to one embodiment, rules and allowance recommendations for allWorkers' Compensation claims in all states of the United States may beselected for being applied to a pre-approval request. FIG. 23 is anexemplary screen capture of a graphical user interface for selecting thevarious states. This screen allows for the selection of the rules of thestate and allowances within the state to be enabled. For states withoutfee schedules, the TAL filter may be enabled for paying a reasonableallowance for care rendered. The CPT with its many rules can optionallybe turned on or off by clicking on or off the option prompt.

Drug Screen Shots

FIG. 24 is an exemplary screen capture of a graphical user interface forenabling a particular drug allowance guide for dispensing medicationsaccording to one embodiment of the invention. One consideration inprescribing medication to a patient is whether the medication has anytherapeutic benefit for the patient's condition. Another considerationis what the cost of the medication would be to a third-party payer.Overcharging for dispensed medications, prescriptions and relatedmedical appliances is not only bad business practice but uses importantresources in an inefficient manner.

Each of the three options illustrated in FIG. 24, that is, DrugAllowance (Redbook), Drug Utilization, and Drug Allowance (MediCal)include a determination of the appropriate allowance for dispensing amedication and for providing information regarding any adverse druginteractions that may be experienced by the patient for the medicationscurrently prescribed. This analysis will include an analysis beingrequested at the instant moment and drug interaction for the drugscurrently being taken by the patient, which have been previouslydispensed.

Claim Environment Screen Shots

FIG. 25 is an exemplary screen capture of a graphical user interface forselecting one or more of different types of claims that the system is toprocess. The rules, authorization considerations, treatment parametersand allowance reimbursement for each of the claim environments aredifferent from each other. In this regard, the automated medical caresystem according to embodiments of the present invention stores in thedatabase 140 the rules, authorization considerations and treatmentparameters for each of the specific claim environments. For example, thesystem does not apply Medicare rules to workers' compensation cases andvice versa. Thus, when a Medicare claim type has been enabled, thevarious filters discussed above apply rules specific to Medicare claims.

Medical Screen Shots

FIG. 26 is an exemplary screen capture of a graphical user interface forselecting an unbundling medical filter and/or a medical literatureevidence based analysis according to one embodiment of the invention.There are a number of prevailing billing practices associated with thedelivery of medical care in the United States. These practices areadhered to in order to improve the quality and efficiency of caredelivered to patients. Unbundling refers to separating services thatwould normally be covered under a single procedure into its parts inorder to increase charges for the service. The practice is abhorred byboth medical peer review and medical authority. The automated medicalcare system includes information in its database which defines everyinstance of unbundling.

The Medical Literature Experience Based Analysis filter is based uponthe world medical literature, which contains information regarding goodmedical care. The database 142 includes numerous articles in theliterature and are configured to be drawn upon to notify the medicalprovider of information that is either of benefit or deleterious in thetreatment of patients. This information is instantly available to betransmitted to any providers questioning the medical validity of thesystem decisions.

Miscellaneous Medical Rules Screen Shot

FIG. 27 is an exemplary screen capture of a graphical user interface forselecting miscellaneous medical rules to be enabled for applying thoserules in the validating or invalidating of medical diagnoses and medicalprocedures according to one embodiment of the invention. In this regard,there are a number of sources of medical care guidelines used todetermine appropriate medical care. These sources contain rules andtreatment parameters that may be invoked in addition to any rulesprovided by the filters described above. For example, the AmericanMedical Association publishes the Current Procedural TerminologyRevision 4 (CPT-4) to define all of the treatments rendered by medicalphysicians in the United States. This document is updated on a yearlybasis and is laden with the valuable medical guidelines. According toone embodiment, all of the guidelines found in the CPT-4 are found inthe database 142 and are appropriately applied by the automated medicalauthorization system according to various embodiments of the presentinvention.

Health Care Financing Administration (HCFA) writes a number of rulesgoverning the appropriate application of medical care. These rules arepublished periodically in the Federal Register. The rules of HCFA arealso incorporated within the database and are appropriately applied whenactivated.

The Medicare Administration further produces documents which define thedelivery of medical care to Medicare patients. The rules of the Medicareadministration are found within the database and are also appropriatelyapplied when activated.

According to one embodiment, each of the option categories mentionedabove can be changed based upon current medical and organizationalnecessity. Further, as the management of medical care changes from timeto time, option field categories can be changed to keep pace withcurrent necessity.

Although exemplary embodiments of the present invention have beendescribed, they should not be construed to limit the scope of theappended claims. Those skilled in the art will understand that variousmodifications may be made to the described embodiments and that numerousother configurations are capable of achieving this same result.

It is the applicant's intention to cover by claims all such uses of theinvention and those changes and modifications which could be made to theembodiments of the invention herein chosen for the purpose of disclosurewithout departing from the spirit and scope of the invention.

1. In a computerized medical care system, a method for providing amedical pre-approval, the method comprising: receiving from a requestingdevice a medical code associated with a medical determination;identifying one or more filters enabled for the computerized medicalcare system; applying the identified one or more filters for thereceived medical code; determining validity of the medical determinationbased on the applied one or more filters; and providing feedback to therequesting device based on the determination of the validity of themedical determination, wherein the feedback prompts modification of themedical determination that is ultimately rendered to a patient if themedical determination is not validated.
 2. The method of claim 1,wherein the medical code is a diagnosis code, the medical determinationis diagnosis of a medical condition, and the one or more filtersincludes a medical diagnosis filter, wherein the feedback is configuredto prompt modification of the diagnosis that is ultimately rendered tothe patient if the diagnosis is not validated.
 3. The method of claim 2,wherein the applying of the medical diagnosis filter and the determiningof the validity of the diagnosis includes: displaying a question thatshould be considered in making the diagnosis of the medical condition;prompting a user response to the displayed question; receiving the userresponse to the displayed question; comparing an expected response tothe displayed question with the received user response; and validatingthe diagnosis if the expected response matches the received userresponse.
 4. The method of claim 2 further comprising: adding to ahistorical database information on the validity of the diagnosis code inassociation with a medical provider providing the diagnosis code;calculating based on information in the historical database a ratio ofcollected diagnosis codes that have not been validated to collecteddiagnosis codes that have been validated; and generating a report basedon the ratio information.
 5. The method of claim 1, wherein the feedbackis a letter including information on the validity of the diagnosis,wherein the letter is generated in real time with the validating of thediagnosis.
 6. The method of claim 1, wherein the medical code is aservice code, the medical determination is a medical service determinedbased on a diagnosed medical condition, and the filters include aplurality of medical procedure filters, wherein the feedback isconfigured to prompt modification of the medical service that isultimately rendered to the patient if the medical service is notvalidated.
 7. The method of claim 6, wherein each of the plurality ofmedical procedure filters are applied one by one in sequence.
 8. Themethod of claim 6 further comprising: providing a graphical userinterface with a list of the plurality of medical procedure filters;receiving a user selection of desired ones of the plurality of medicalprocedure filters; and enabling each selected medical procedure filterfor applying in making the validity determination of the determinedmedical service.
 9. The method of claim 6, wherein the applying of atleast one of the plurality of medical procedure filters includes:analyzing historical data collected in association with the service codefrom a historical database; determining based on the analyzed historicaldata whether the medical service is statistically reasonable; andreturning a result of applying the at least one of the plurality ofmedical procedure filters based on the determination.
 10. The method ofclaim 9 further comprising: adding to the historical databaseinformation on the medical service determined for the medical condition.11. The method of claim 6, wherein at least one of the plurality ofmedical procedure filters is a heat filter, and the applying of the heatfilter includes: identifying a date of injury; identifying a timing ofthe medical service, wherein the medical service is a heat-basedtherapy; determining whether the timing of the heat-based therapy isappropriate relative to the date of injury; and returning a result ofapplying the heat filter based on the determination.
 12. The method ofclaim 6, wherein at least one of the plurality of medical procedurefilters is a rarity filter, and the applying of the rarity filterincludes: retrieving historical data of medical services provided forthe diagnosed medical condition; identifying a rate in which thedetermined medical service was provided for the identified diagnosisbased on the retrieved historical data; identifying a threshold rate;determining whether the identified rate satisfies the threshold rate;and returning a result of applying the rarity filter based on thedetermination.
 13. The method of claim 6, wherein at least one of theplurality of medical procedure filters is a utilization filter, and theapplying of the utilization filter includes: receiving information on arequested number of visits or duration of care for the identifiedservice code; analyzing historical data of previous number of visits ordurations of care provided for the diagnosed medical condition;identifying a threshold number of visits or durations of care based onthe analyzed historical data; determining whether the requested numberof visits or duration of care satisfies the threshold number of visitsor duration of care; and returning a result of applying the utilizationfilter based on the determination.
 14. The method of claim 6, wherein atleast one of the plurality of medical procedure filters is a level ofservice filter, and the applying of the level of service filterincludes: identifying a level of service associated with the identifiedservice code; analyzing historical data of previous levels of serviceprovided for the diagnosed medical condition; identifying a thresholdlevel of service based on the analyzed historical data; determiningwhether the identified level of service satisfies the threshold level ofservice; and returning a result of applying the level of service filterbased on the determination.
 15. The method of claim 6, wherein at leastone of the plurality of medical procedure filters is a billingguidelines filter, and the applying of the billing guidelines filterincludes: receiving a requested charge amount for the determined medicalservice; identifying a billing guideline associated with the determinedmedical service; determining whether the requested charge amountsatisfies the identified billing guideline; and returning a result ofapplying the billing guidelines filter based on the determination. 16.The method of claim 6, wherein at least one of the plurality of medicalprocedure filters is a charges filter, and the applying of the chargesfilter includes: receiving a requested charge amount for the determinedmedical service; analyzing historical data of previous chargesassociated with the diagnosed medical condition; identifying a thresholdcharge amount based on the analyzed historical data; determining whetherthe identified charge amount satisfies the threshold charge amount; andreturning a result of applying the charges filter based on thedetermination.
 17. The method of claim 6, wherein the feedback is aletter including information on the validity of the medical service,wherein the letter is generated in real time with the validating of thedetermined medical service.
 18. The method of claim 6, wherein theapplying of at least one of the plurality of medical procedure filtersincludes: identifying a specific patient for which the medical serviceis determined; retrieving historical data of medical care provided tothe specific patient; determining based on the retrieved historical datawhether the determined medical service is appropriate for the specificpatient; and returning a result of applying the at least one of theplurality of medical procedure filters based on the determination.
 19. Acomputerized medical care system for providing a medical pre-approval,the system comprising: a processor; and a memory operably coupled to theprocessor and storing program instructions therein, the processor beingoperable to execute the program instructions, the program instructionsincluding: receiving from a requesting device a medical code associatedwith a medical determination; identifying one or more filters enabledfor the computerized medical care system; applying the identified one ormore filters for the received medical code; determining validity of themedical determination based on the applied one or more filters; andproviding feedback to the requesting device based on the determinationof the validity of the medical determination, wherein the feedbackprompts modification of the medical determination that is ultimatelyrendered to a patient if the medical determination is not validated. 20.A computerized medical care system for providing a medical pre-approval,the system comprising: a computing engine configured to receive adiagnosis code identifying diagnosis of a medical condition and aservice code identifying a requested medical service; a medicaldiagnosis filter coupled to the engine and configured to display aquestion that should be considered in making the diagnosis of themedical condition, the medical diagnosis filter further being configuredto prompt a user response to the displayed question, validate thediagnosis if the expected response matches the user response, andinvalidate the diagnosis if the expected response fails to match theuser response; and a plurality of medical procedure filters coupled tothe engine and configured to determine a validity of the requestedmedical service relative to the diagnosis based on each of the appliedmedical procedure filters, wherein the computing engine is configured toprovide feedback based on the determination of the validity of thediagnosis and requested medical service, wherein the feedback promptsmodification of the diagnosis or medical service that is ultimatelyrendered to a patient if respectively the diagnosis or requested medicalservice is not validated.